Physical Assessment of the Respiratory System Day 2A.

Physical Assessment of the Respiratory System

Day 2A

History

• Physical problems• Function problems• Life style• Smoking• Family Hx• Occupation hx• Allergens / environment• Recreational exposure• Anxiety• S&S

• The nurse is teaching a group of prenatal clients about the effects of cigarette smoke on fetal development. Which characteristic is associated with babies born to mothers who smoked during pregnancy?

A. Low birth weightB. Large for gestational ageC. Preterm birth, but appropriate size for gestationD.Growth retardation in weight and length

Inspection

• Normal chest– Slight retraction of

intercostal spaces– 2x as wide as deep– Anterior/posterior

diameter• 1:2

Inspection

• Barrel chest– D/t over inflation of

lungs– anterior-posterior

diameter • 2:2

Inspection

• Funnel chest– Depression of the

lower portion of the sternum

– Complications• Heart damage• Cardiac output

– Nrs management• Murmurs

Inspection

• Pigeon chest– Sternum protrudes

outward– anterior-posterior

diameter•

Inspection

• Scoliosis– Lateral curvature of

thoracic spine– Assessment

• Shoulders elevated?

– Complications• Lung & heart damage• Back problems• Body image

Quiz?

• How many hours a day should a child wear a brace for treating scoliosis?

A. 8 hrB. 12 hrC. 23 hrD. 24 hr

Inspection

• Kyphosis– AKA

• Hunchback

– Abnormal curvature of the thoracic spine

Inspection

• Lordosis– AKA

• Sway-back

– Abnormal curvature of the lumbar spine

Inspection

• Uniform expansion of the chest– Pneumonia– Pleural effusion– Pneumothorax

• Bulging intercostal spaces– Obstruction– Emphysema

Inspection

• Marked retraction of intercostal spaces– Blockage

• Shoulder rise• Accessory muscles• Posture

Inspection: Breathing patterns

Rate• Eupnea– Normal– 12-20 / min

• Tachypnea– rate– Pnuemonia, pulm edema, acidosis, septicemia, pain

• Bradypnea– rate– ICP, drug OD

Inspection: Breathing patterns

Depth• Hyperpnea– depth

• Hyperventilation– depth & rate

• Hypoventilation– depth & rate

Inspection: Breathing patterns

Depth• Kussmaul's– rate & depth– Assoc. with sever acidosis

• Apneustic– Prolonged gasping I following by short

Inspection: Breathing patterns

Rhythm• Apnea– Not breathing

• Cheyne-stokes– Varying depth f/b apnea– Death rattles– Death rales

Inspection: Breathing patterns

Rhythm• Biot’s– rate & depth w/ abrupt pauses– Assoc w/ ICP

Inspection:

• Trachea– ? Deviation

• Pleural effusion• Tension pneumothorax• Atelectasis

• Color• LOC• Emotional state

Palpation

• TML– Tenderness (T)– Masses (M)– Lesions (L)

• Sinuses– Palpate below eyebrow &

Cheekbone• Crepitus

– Subcutaneous emphysema– Air leaks into the sub-q tissue

Percussion

Rational• To determine if underlying

tissue is filled with air or solid material

Procedure• Pt sitting• Tap starting at shoulder• compare rt to lf

Percussion: results

• Resonance – drum like– Normal

• Hyper-resonance– Too much air– Emphysema

• Flatness / dull– Fluid or solid– Pleural effusion– Pneumonia– Tumor

Auscultation

Purpose• Asses air flow through

bronchial treeProcedure• Diaphragm of

stethoscope• Superior inferior• Compare rt to lf

Auscultation: Results

Normal• Vesicular

– Lung field– Soft and low

• Bronchial– Trachea & bronchi– Hollow

• Bronchovesicular– Mixed– Between scapulae– Side of sternum– 1st & 2nd intercostal space

Auscultation: Results

Adventitious• Crackles– Rales– air bronchi with

secretions

• Fine crackles– Air suddenly

reinflated

• Course Crackles– Moist

Auscultation: Results

• Wheezes– Sonorous wheezes

• Deep low pitched• Snoring• > E• Caused by air

narrowed passages• D/t secretions

– Sibilant Wheezes• High pitched• Whistle-like• I & E• Caused by air

narrowed passages• D/t constriction

– Asthma

Auscultation: Results

• Pleural friction rub– D/t inflammation of

pleural membranes– Grating, creaking– I & E– Best heard

• Anterior, Lower, lateral area

Auscultation: Results

• Stridor– Crowing – Partial obstruction of

the larynx or trachea

Quiz?

• A child with difficulty breathing and a “barking” cough id displaying signs associated with which condition?

A. AsthmaB. CroupC. Cystic fibrosisD. Epiglottitis

Quiz?

• When assessing the lung sounds of a child with asthma, which sound are you most likely to hear?

A. MurmursB. Sonorous WheezingC. Sibilant WheezingD. CracklesE. Pleural friction rub

Early & late signs of hypoxia

• Anxiety• Bradycardia• Cyanosis• Depressed respirations• Diaphoresis• Disorientation• Dyspnea

• Restlessness• Headache• Agitation• Poor judgment• Retraction• Tachycardia• Tachypnea

The nurse recognizes which of the following as an early sign of hypoxia?

A. Restlessness, yawning & tachycardiaB. Dyspnea, confusion & bradycardiaC. Bradycardia, hypotension dyspneaD. Dyspnea, restlessness, hypotension

Dyspnea

• Definition– SOB

–SOB, flat affect, BS x 4

Dyspnea

• Significance– Common with cardiac & resp. disease– Sudden onset – healthy person • Pneumothorax

– Sudden onset ill, post-op or injury • Pulmonary emboli

Dyspnea

• Orthopnea– Sit up to breath• COPD• CHF

Dyspnea

• Right ventricle– If chronic airway resistance – pressure – Rt ventricle work – Rt. Vent damage

Dyspnea

• Nrs Management– Find cause– Give O2

– HOB – Communication• KISS

Cough

• Definition– To expel air from the lungs suddenly– Irritation of mucous membrane

Cough

• Significance– Infection– Irritants– Protective mechanism– Dry, irritating• URT

– Cough + chest pain• Pleural or musculoskeletal

Cough

• Nrs management– Assess– Describe – Directed – Pain control• Splinting

– Infection control– Suppressants / Anti-tussives

Sputum Production

Definition• Matter discharged

from resp. track that contains mucus and pus, blood, fibrin, or bacteria

Sputum Production

Significance• Purulent– Thick, yellow/green – Bacteria

• Rusty – Strep or staph

• Thin, mucous – Viral

Sputum Production

• Pink-tinged– Lung CA– TB

• Pink tinged, profuse, frothy– Pulmonary edema

• Malodorous– Lung abscess

Sputum Production

Nrs Management• Thick– Hydrate

• water• Nebulizer• Humidifier

• TCDB• No smoking• Oral care• Appetite

Do You Know?????

What breath sound would you expect to hear on a patient with increased sputum production?

A. VesicularB. CracklesC. Sonorous wheezesD. Sibilant wheezes

Obtaining a sputum specimen

• Explain– From lungs

• Sterile cup• Deep breath x 3 • Cough deeply• Expectorate • Best time for

specimen collection?– AM

A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Whichaction should the nurse take first?

A. Ask client to cough sputum into containerB. Have the client take several deep breathsC. Provide a appropriate specimen containerD.Assist with oral hygiene

Chest pain

Definition• Cardiac or pulmonary

Chest pain

Significance• CA (late stage)• Pneumonia• Pulmonary embolism• Pleurisy

Chest pain

• Pleurisy– Inflammation of pleura– Sharp with breath– breath sounds

What?????

What breath sound would you expect to hear on a patient suffering from pleurisy?

A. CracklesB. Sonorous wheezesC. Sibilant wheezesD. Pleural Friction Rub

Chest pain

Nrs Management• Assess• Analgesics OK, but…• Position for pain– Affected side– Splint

Clubbed fingers

Definition• Sponginess of the nail

bed • Loss of the nail bed

angle• Finger tip is round and

bulbous

Clubbed Finger

Significance• chronic hypoxiaNrs Management• Marker

Mr. Caveman:

Mr. Caveman enters the ER unconscious following an Automobile accident. The paramedics report that his O2 sats are 86%. You note that Mr. Caveman has clubbed fingers. What does this tell you?

Hemoptysis

Definition• Expectoration of blood

from the respiratory tract

Hemoptysis

Significance• Pulm or cardiac• Common causes– Pulm infection– CA of lungs– Pulm. Emboli– Pulm. Infarction– TB

Hemoptysis

• Hemoptysis– Definition?

• Coughed up blood

– From?• Pulm hemorrhage

– Description• Pink, red, mixed with

sputum

– Blood pH• Alkaline blood

• Hematemesis– Definition?

• Vomited blood

– From?• Stomach / GI

– Description• “Coffee ground”

– Blood ph• Acidic blood

Hemoptysis

Nrs Management• Determine source• Serious

Cyanosis

Definition• Bluish coloring of skin

Cyanosis

Significance• Very late indicator of

hypoxia• Appears when O2 sats

< 85%• NOT a reliable sign of

hypoxia– Esp. with anemia

Cyanosis

• O2 sat definition– % of hemoglobin

carrying oxygen compared to total # of hemoglobin

Cyanosis

• NormalBreath 100 O2 molecules 98 cross into blood

Blood: 100 Hgb• O2 SATS– 98%– No cyanosis

Cyanosis

• HypoxiaBreath 100 O2 molecules 75 cross into blood

Blood: 100 Hgb• O2 SATS– 75%– Cyanosis

Cyanosis

• Anemic and hypoxicBreath 100 O2 molecules 75 cross into blood

Blood: 75 Hgb• O2 SATS– 100% – No Cyanosis

Cyanosis

Nrs. Management• Know color of Pt. skin• Assess color of tongue &

lips• Fingernail polish• African-American• Vasoconstriction (cold

weather) peripheral cyanosis